Consent: Recruitment Database for Literacy Research
Participate in reading research!
The Recruitment Database collects contact information for families interested in participating in research studies on literacy with the Brain, Education, and Mind (BEAM) Lab at the MGH Institute of Health Professions (MGH IHP), led by Dr. Joanna Christodoulou.
You are being asked to complete the following survey because you have a child, and you are interested in participating in research studies pertaining to literacy. The survey includes a brief survey about your child's background, technology access, and your contact information. We expect the survey to take about 3 minutes to complete.
The information collected in this survey will be stored in a secure database and will be used for research recruitment purposes. Only research staff in the BEAM Lab at the MGH IHP will have access to the information you provide. By completing this survey, you agree to be contacted about research studies if your child is an appropriate candidate. If you are contacted, you have no obligation to participate. This survey is completely voluntary, and you can choose to stop at any time. Deciding not to participate won't affect medical care you receive from Mass General Brigham now or in the future. If at any time you decide not to include your child's information in this database, you can contact the researchers at beamstudies@mghihp.edu and your child's information will be removed. If you have any questions about the Recruitment Database, feel free to contact the Primary Investigator, Dr. Joanna Christodoulou, at beamstudies@mghihp.edu .
If you'd like to speak to someone not involved in this research about your rights as a research subject, or any concerns or complaints you may have about the research, contact the Mass General Brigham Human Research Committee at (617) 424-4100.
We are required by the Health Insurance Portability and Accountability Act (HIPAA) to protect the privacy of health information obtained for research. This is an abbreviated notice, and does not describe all details of this requirement (see Mass General Brigham Privacy Notice*). During this survey, identifiable information about you or your health will be collected and shared with the researchers in the lab listed above. In general, under federal law, identifiable health information is private. However, there are exceptions to this rule. In some cases, others may see your identifiable health information for purposes of research oversight, quality control, public health and safety, or law enforcement. We share your health information only when we must, and we ask anyone who receives it from us to protect your privacy. *Mass General Brigham HealthCare Notice for Use and Sharing of Protected Health Information http://www.partners.org/Assets/Documents/Notices/Partners_Privacy_Policy_English.pdf
* must provide value
I agree I do not agree
You have been invited to participate in this research study conducted by the Brain Education and Mind (BEAM) Lab at the MGH IHP and the Gabrieli Lab at MIT because you have expressed interest in this study and your child may be eligible. The purpose of this questionnaire is to determine your child's eligibility to participate. Participation is voluntary. You have the right not to answer any question, and to stop the questionnaire at anytime and for any reason. We expect that this questionnaire will take 5‐10 mins. Any information that is obtained that can identify you will remain confidential and will be disclosed only with your permission or as required by law. Your information will be discarded if we determine that you are not eligible to participate in this study. If you have any questions please contact beamstudies@partners.org.
We are currently inviting participants in Kindergarten-5th grade who are:
• Typically developing readers, or
• Struggling with reading and/or attention
*Please note that not every family who fills out our screening survey will qualify for one of our current studies. Once you fill out the screening survey, we will be in touch to let you know about study eligibility and scheduling. Thank you!
Thank you for your interest in our research!
Researchers at MIT, MGH, and the MGH Institute of Health Professions are conducting a research study on children's reading skills. We are currently recruiting children in kindergarten through 5th grade. If you and your child are interested in participating, please enter your information into our recruitment database below.
If you have more than one interested child in K-5th grade, please complete this form more than once.
Parent/Guardian's Name:
* must provide value
Parent/Guardian's Phone Number:
* must provide value
Parent/Guardian's Email:
* must provide value
Preferred Method of Contact (choose one or more)
* must provide value
How did you learn about this study? (choose one or more)
Could you please describe the recruitment source further (e.g., "I saw it on a friend's Facebook post," "My school, Main St. Elementary, emailed us," "My child's friend participated and told us all about it," etc.)?
Child's First Name:
* must provide value
Please enter ______ 's date of birth (month-day-year)
* must provide value
M-D-Y
Which grade did ______ complete in the 2022-2023 school year?
* must provide value
Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
Other
Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
Other
Which grade did ______ complete in the 2023-2024 school year?
* must provide value
Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
Other
Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
Other
Which grade will ______ begin in the fall of 2024?
* must provide value
Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
Other
Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
Other
If other, please specify:
Boy
Girl
Other
Prefer not to answer
Boy
Girl
Other
Prefer not to answer
Did ______ speak English at home or at school/daycare before kindergarten?
* must provide value
Yes
No
Other
If you selected other, please describe:
Was your child born full term?
Yes
No
At how many weeks was your child born?
Please indicate if ______ has been identified with any of the following:
* must provide value
If you selected other, please describe:
Does ______ have any metal in their body (including braces, permanent retainer, pacemaker, cochlear or other implants, pumps, etc.)?
* must provide value
Yes
No
Not sure
Please explain what metal your child has in/on their body.
If your child does not have braces (or other orthodontia), will they be getting braces soon? Please explain.
Does ______ require glasses to read?
* must provide value
Yes
No
Does ______ have normal hearing?
* must provide value
Yes
No
Is there any other information about your child that you think might be relevant to this study?